Preoperative Risk Evaluation Major Pre-Op Questions: 1. Does the patient have any modifiable risk factors that could be optimized before surgery? 2. Would delaying the surgery increase the patient’s perioperative risk or morbidity? 3. Does the patient have enough info regarding the risk of the surgery to make an informed decision? Key Components: 1. Take a thorough history (specific questions to ask) - Any adverse events or complications from anesthesia in the past - personal or family - Ever been intubated in the past? If yes, any mention of a difficult airway - Allergies to medications? - Any implantable devices? 2. Assess functional status - Able to perform own ADLs - Highest metabolic equivalent able to perform? 4 Mets = Climbing a flight of stairs, brisk 4 mph walk 3. Performance thorough physical exam - Key components: - CV exam (any evidence of fluid overload, irregular rhythm, new murmur 3/6) - Pulmonary exam - Skin exam for infection - Baseline neuroexam - Oral cavity/Airway exam Determine Cardiac Risk: RCRI: 1. Risk of the particular surgery 2. Preop creatinine 3. Medical history of: a) Ischemic heart disease b) CHF c) CVA 4. Insulin dependent DM ACS NSQIP: 1. Risk for particular surgery 2. Preop creatinine 3. Age 4. Functional status 5. ASA class If high risk > 1% risk of CV event, follow ACC algorithm to determine if stress test is indicated • EKG Indicated? Obtain EKG if: - Known CV disease - Arrhythmia - Structural heart disease • Echo indicated? - Patients with valvular dysfunction or LV dysfunction or a. Change in clinical status or physical exam since last echo b. Stable patients with no echo in the last year Risk Stratify Type of Surgery: • High risk (>5%): - Aortic - Peripheral vascular • Intermediate (1-5%): - Intrathoracic - Intraabdominal - Orthopedic • Low risk (<1%): - Endoscopic procedures - Cataract Plan for Meds: 1. Anticoagulation - what is the bleeding risk of surgery? What is the type of and indication of AC? 2. ACEi/ARBs - Hold day of surgery 3. Diabetes regimen 4. NSAIDs - Hold 7 days before 5. VITAMINS/supplements - Hold 7 days before Pulmonary: • Smoking - quit > 8 weeks before surgery • Screen for OSA • Continue CPAP if they have one post op Cardiology: 1. Recent PCI/stenting 2. Severe Aortic stenosis 3. Unstable Angina Delay elective surgery if... • <6mo since elective PCI/DES ( Levine 2016) • <12mo since ACS ( Levine 2016) • <6mo since stroke ( Doherty 2017) • <3mo since VTE Determine if any labs are needed: • HgbA1c - if not done in last 3 months • Creatinine - needed if result will change CV risk Chest X-ray: • Not indicated unless prior heart/lung issues • Older > 50 years and undergoing AAA or upper abdominal/thoracic surgery Stress Testing: • Preoperative coronary revascularization does not seem to prevent postoperative cardiac events or death (CARP, DECREASE V trials) • BUT, preoperative stress testing may inform risk discussions, perioperative medical and surgical management for select patients #Preop #preoperative #perioperative #Risk #Evaluation #stratification #diagnosis
